The Broughtons

The Broughtons is a residential care home which provides personal care and accommodation for the older people, located in Salford, Greater Manchester. The home is registered with the Care Quality Commission (CQC) care for up to 42 people. At the time of this inspection there were 37 people living at the home.

People’s experience of using this service and what we found

Medicines were managed safely, with improvements made since our last inspection. Appropriate recruitment procedures were in place and the feedback we received informed us there enough staff working at the home to care for people. Staff wore personal protective equipment (PPE) throughout the inspection and lateral flow testing (LFT) was carried out. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. The policies and systems in the service supported this practice.

We received positive feedback from people who used the service and relatives about management and leadership at the home. Staff said they felt supported and that staff worked well together. Systems were in place to monitor the quality of service through audits, meetings and satisfaction surveys.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published March 2020). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from requires improvement to good. This is based on the findings from this inspection.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

Follow up

We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Broughtons is a residential home located in the Salford area of Greater Manchester and is operated by Wellbeing Residential Limited. The home is registered with the Care Quality Commission (CQC) to provide care for up to 42 people.

People’s experience of using this service and what we found

Further improvements were required to the safe administration of people’s medication. Some actions from the last fire risk assessment also remained outstanding. Improvements were required to governance and auditing systems to ensure these concerns were identified and acted upon in a timely way.

People felt safe using the service and staff displayed good knowledge about how to protect people from the risk of harm. Appropriate staff recruitment checks were carried out and there were detailed risk assessments in place regarding the care and support people received.

People received the support they needed to eat and drink. Appropriate referrals were made to other health professionals where there were concerns about people’s nutritional status. Staff told us they were happy with the level of training, support and supervision available to develop them in their roles.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Improvements had been made regarding restrictive practices since our last inspection.

We received positive feedback from everybody we spoke with about the care and support provided at The Broughtons. People said they felt well cared for by staff and were treated with dignity and respect.

Appropriate systems were in place to manage complaints. A number of compliments had been received by the service. Activities took place for people to participate in if they wished. People’s end of life care wishes were also discussed and respected by staff.

Staff told us they were happy working at the service. Feedback about management and leadership was positive and there were opportunities for staff to discuss their work at monthly staff meetings.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last inspection at The Broughtons was in December 2018 (published 16 February 2019). The overall rating was Requires Improvement, where three breaches of the regulations were identified regarding need for consent, safe care and treatment and Good Governance.

Why we inspected:

This was a routine comprehensive inspection and in line with our timescales for re-inspecting services previously rated Requires Improvement.

Follow up:

We will continue to monitor information and intelligence we receive about the service and will return to re-inspect in line with our inspection timescales. However, if any information of concern is received, we may inspect sooner.

The Broughtons provides residential care for up to 42 elderly people. The home is a detached building, situated in a residential area of Salford and is close to local shops and public transport. Parking facilities are available to the front and side of the building.

Rating at last inspection:

Our last inspection of The Broughtons was in October 2017. The overall rating was Requires Improvement and this report was published on 25 November 2017.

People’s experience of using this service at this inspection:

During this inspection of The Broughtons on 13 and 17 December 2018, we found improvements were required to the safe handling of people’s medication and obtaining consent from people regarding potential restrictive practices. Quality assurance systems also needed to be improved to ensure the concerns from this inspection were identified and acted upon in a timely manner. The principles of the mental capacity act (MCA) were not always being adhered to.

Staff were recruited safely and there were sufficient numbers of staff to care for people safely.

The building and the premises were well maintained, with all relevant safety checks being undertaken.

Appropriate systems were in place to monitor accidents and incidents.

Staff received the necessary induction, training, supervision and appraisal to support them in their roles.

People received enough to eat and drink and received appropriate support at meal times.

People living at the home and visiting relatives made positive comments about the care provided at the home.

People said they felt treated with dignity and respect and that staff promoted their independence as required.

Appropriate systems were in place regarding end of life care

Complaints were handled appropriately. Compliments were also maintained about the quality of service provided.

There were a range of activities available for people to participate in.

We received positive feedback from everybody we spoke with about management and leadership within the home.

More information is in detailed findings below. We identified three breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 relating to medication, consent and governance. Details of action we have asked the provider to take can be found at the end of this report.

Why we inspected:

This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received. Inspection timescales are based on the rating awarded at the last inspection and any information and intelligence received since we inspected. As we rated the service Requires Improvement at the last inspection, this meant we needed to re-inspect within approximately 12 months of this date.

Follow up:

We will continue to monitor information and intelligence we receive about the home to ensure good quality is provided to people. We will return to re-inspect in line with our inspection timescales for Requires Improvement services, however if any information of concern is received, we may inspect sooner.

The Broughtons is registered to provide accommodation and personal care for up to 39 older people. The home is a detached building, situated in a residential area of Salford and is close to local shops and public transport. Parking facilities are available to the front and side of the building.

The service was last inspected on 22 February 2017, when we rated the service as ‘requires improvement’ overall. During that inspection we identified five continuing breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

These breaches related to the safe and effective management of people’s topical creams and drink thickening agents, monitoring of peoples nutritional and hydration requirements when being assessed at risk of malnutrition and or dehydration, the unlawful withholding of people’s cigarettes without the required legal assessments being completed, care files not detailing the appropriate information pertaining to their individual care requirements and the service continuing to have inadequate internal quality assurance monitoring systems in place.

During the inspection we also found the service to be in breach of a sixth regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, where we found the service building and premises were not clean and properly maintained for the purpose they were being used.

Following the inspection we wrote to the provider to determine what immediate action would be taken to ensure the premises were appropriately maintained and fit for purpose. The provider responded to our request with a full audit of the building and a time scale for the work to be completed. In addition to this we also took enforcement action and issued the provider and registered manager with a regulation 17 warning notice in relation to good governance. This was to formally request the service take action be taken to ensure quality assurance and auditing systems were in place and being utilised.

At this inspection we found that the breaches we had previously found relating to the safe management of people’s topical creams and fluid thickening agents, the lack of legal assessments when withholding items from people who lacked capacity, care files not containing the appropriate information pertaining to their individual care requirements and the building and premises not being effectively maintained and clean had now been addressed and the service was no longer in breach of these areas.

However, although we found improvements had been made in relation to the management of people’s risks around dietary requirements we found on two occasions the service had failed to refer two people to the relevant health professionals in a timely manner. This has resulted in a breach of regulation 12 (2) (i) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 with regards to safe care and treatment.

Again, although we saw improvements had been made at this inspection around the implementation of service governance and audit systems, we found in some cases audits had not identified the issues which have been raised throughout the report. This was a continued breach of Regulation 17, (2) (c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We also found the service to be in breach of Regulation 17 (2) (c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because one person who had resided at the service since August did not have a full care plan in place at time of this inspection and in addition to this the service had failed to update a person’s care file in relation to their changing mobility needs.

We have also made a recommendation that the registered manager seeks advice and guidance from the local authority in relation to conditions which apply to people’s Deprivation of Liberty Safeguards assessments.

There was a manager in post at time of inspection. The registered manager had been employed at the service since October 2010. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was supported in her role by the company’s director and service’s quality and compliance manager.

People expressed satisfaction with the service provided. People told us they felt safe and were confident the care received was delivered by professional and caring staff.

At time of inspection extensive building and refurbishment work was underway. This was to improve both internal and external areas. In addition to this the service director provided us with a full refurbishment plan which had timescales for the work to be completed.

The provider ensured processes were in place to maintain a safe and appropriate environment for people, their relatives/visitors and staff members. Staff members we spoke with felt they were equipped with a suitable amount of training to ensure they had the correct skills and knowledge to effectively support people in an informed, confident and self-assured manner. Staff felt confident with recognising the signs of abuse and demonstrated they could appropriately and confidently respond to any safeguarding concerns and notify the relevant authorities when required.

The service complied with the requirements of fire safety regulations by ensuring fire audits were up to date and relevant checks were carried out on a weekly basis to fire equipment and lighting. People using the service had personal evacuation risk assessments in place and an additional contingency plan provided direction about what to do in the case of an emergency or failure in utility services or equipment.

Recruitment processes were robust and designed to protect people using the service by ensuring appropriate steps were taken to verify a new employee’s character and fitness to work.

The service had a sufficient number of staff to support the operation of the service and provide people with safe and personalised care. People told us they never felt rushed and staff were responsive to their needs. The registered manager told us the service was currently recruiting for additional members of staff to enable a further person to be present throughout the day to meet the requirements of current people’s needs.

Processes were in place for appropriate and safe administration of medicines. Staff were trained in medicines administration. Medicines were stored safely and in line with current guidance. People had been consulted about their dietary requirements and preferences and we saw choice was given at every mealtime. Topical creams were now appropriately administered and fluid thickening agents were detailed on people’s medicines records and signed when given.

We looked at eight care files. We found improvements and additions had been made since the previous inspection. They now detailed guidance for staff to follow, to ensure people’s needs were being met in a person centred way.

Appropriate capacity assessments and best interest decisions had now been considered when considering people who lacked the ability to consent to the service holding items such as cigarettes.

Staff interacted and engaged well with people. Staff were caring, respectful and understanding in their approach and treated people as individuals. They promoted privacy and dignity and supported people to maintain control over their lives. Their opinions were routinely sought and acted upon by means of questionnaires and residents meetings. This enabled people to influence to the service they received.

Positive feedback was received from people using the service, visitors and staff about the management structure. People told us they were able to ask for assistance from the registered manager when required and people also informed the registered manager was present throughout the day in the communal areas. Staff also informed they felt well supported and they could approach either manager with any concerns.

The Broughtons provide residential care for up to 39 elderly people. The home is a detached building which is situated in a residential area of Salford and is close to local shops and public transport. Parking facilities are available to the front and side of the building.

At the last comprehensive inspection on the 6 July 2016 six breaches of legal requirements were found. These were relating to medicines management, governance systems, safeguarding, person centred care, staffing, dignity and respect. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements.

During this comprehensive inspection we found the service was now in breach of six Regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to a continued breach of safe management of topical creams and fluid thickening agents, privacy and dignity issues, the management of people's hydration, safeguarding in relation to withholding people’s cigarettes and audit systems. And additional breach has been added in relation to the suitability of the environment. You can see what action we told the registered provider to take at the back of the full version of the report.

At the time of inspection the service had a registered manager who had been registered with the Commission since, October 2010. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements as set out by the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found although improvements had been made in the safe handling of medicines. There were still improvements to be made around the administration and documentation of topical creams and fluid thickening agents. We also noted there were some gaps in the medicines administration records where signatures had been missed from previous medicines round.

People using the service told us they were happy with the way they had their medicines administered and they felt they always had their correct dose on time each day. We observed medicines management which was effectively and safely done.

People told us they considered themselves safe whilst living at The Broughtons. They also indicated the care they received was delivered in a professional and caring way and staff had the correct skills to undertake their role effectively.

The service ensured referrals to agencies such as the falls team and dieticians had been made for people who had been assessed at high risk of falls or pressure areas.

People told us they were provided with personalised care which was carried out in a respectful way. However, we found care files lacked detail for staff in relation to people’s assessed needs and preferences. People’s details about their daily living requirements were also incomplete in the care files we saw.

There were numerous areas of improvement required to the environment. Carpets were stained and malodourous’, the conservatory area was being used for storage:, therefore people could not access it safely. Several toilet/bathroom areas were out of order and we observed holes in walls in the corridors. Following the inspection we wrote to the provider to ascertain their intention to rectify this position. The provider completed a full audit of the premises and provided us with an action plan for work to commence and be completed.

Staffing number observations on the day of the inspection were positive. People’s needs were being met, however the service still only employed one senior care assistant to work during the night. The registered manager informed another senior member had been recruited and until the person commenced work a second senior member of staff was required to be on call from home during the night.

A robust recruitment system had been implemented. Appropriate steps were taken to verify new employee's character and fitness to work. Following successful appointment to the role the provider ensured a thorough induction plan was carried out which ensured staff were equipped with the correct skills and knowledge to effectively support people in an informed, confident and self-assured manner.

The service also offered a variety of training to staff which helped to ensure the staff team were skilled and experienced in safely and effectively supporting the people using the service.

Staff displayed a limited awareness of the Mental Capacity Act 2005 and other staff were waiting to complete appropriate training. However not all staff had an understanding around Deprivation of Liberty Safeguards.

People spoken with knew the registered manager and were able to inform us what they would do should they have a complaint. Staff told us they felt the registered manager was approachable.

A variety of activities were offered to people. People spoke about the trips out and told us activities happened each day.

We found lack of audit systems in place. We asked the registered manager on the day of inspection for numerous audits to evidence the on-going compliance of the service was being monitored. However the registered manager could not produce these at time of inspection. Audits had failed to identify issues we had raised at time of inspection. The homes policies had not been updated and reviewed since 2015. Following the inspection the registered manager wrote to us to say that these policies were in fact on the computer system, however we did not see any evidence of this only the policies that were presented to us at time of inspection.

The Broughtons provides residential care for up to 39 elderly people. The home is a detached building, situated in a residential area of Salford and is close to local shops and public transport. Parking facilities are available to the front and side of the building.

At our last inspection of The Broughtons on 30 September 2014, we found the home was meeting all of the standards assessed.

During this inspection we found eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment (two parts), staffing (two parts), person centred care, dignity and respect, safeguarding and good governance. You can see what action we have asked the home to take at the back of the report.

People living at the home told us they felt safe as a result of the care they received. Staff also displayed a good understanding of safeguarding and how they would report concerns.

We found staff were recruited safely, with appropriate checks undertaken before staff started working at the home.

We found medication was not handled safely. There were no photographs of people on their Medication Administration Records (MAR’s), to reduce the risk of confusion and ensure medicines were given to the correct person. We also found there were no cream charts in place, to demonstrate when creams were applied and to what areas of the body.

We found there wasn’t always sufficient staff with the correct skills to look after people living at the home at night. On the night of 5 July 2016, one person had asked for pain relief during the night, however there were no trained staff on shift to administer this safely.

People had risk assessments in their care plans covering areas such as mobility, nutrition and pressure sores, however we found these were out of date and needed to be reviewed. Risk assessments were also not reviewed following accidents and incidents.

We observed one person who was at risk of skin breakdown and needed to be sat on a pressure relieving cushion wasn’t sat on one during the inspection, despite raising this with a member of staff.

The environment was not consistently safe. When we arrived at the home and throughout the day, we saw tools such as a power drill and saw had been left unattended in a bedroom which was being refurbished. This increased the risk of people accessing the tools in an unsafe manner, placing people a risk.

Staff told us they received enough training and felt well supported. However two members of staff we spoke with felt they had not been provided with sufficient training and induction since working at the home, yet had been expected to oversee the home in the absence of the home manager. This included being provided with training such as moving and handling.

Staff told us they received supervision at regular intervals from their line manager. We saw records to confirm these had taken place.

We saw the environment at the home was not dementia friendly, with little signage around the building to help people orientate themselves around the building and establish where they needed to go.

We saw restrictive practice in operation at the home. For example, one person’s cigarettes were kept on a trolley which the staff dispensed at certain intervals. We could not find a capacity assessment, restrictive screening tool or evidence that a best interest meeting had been convened regarding this practice in the person’s file.

The people living at the home and their relatives told us they were happy with the care provided. They told us staff were kind and caring.

We saw instances where the privacy and dignity of people living at the home was compromised. On arrival at the premises we saw that people’s underwear was hung over the handrails in the corridors outside their bedrooms. Another person used a urine bottle in their bedroom, however this was left on display, with this person also telling us staff did not always empty it in a timely manner. We also observed this person had baked beans on their clothing, approximately two hours after eating their lunch.

We identified one person living at the home, who did not have a care plan in place, despite living at the home for several weeks. The other care plans we looked at were not updated and reviewed at regular intervals. The care plans we looked at also did not contain photographs of each person. This would make it easier for staff to identify the correct people when delivering care. Two visiting relatives also said they didn’t feel involved in the care of their family member.

We saw complaints were handled appropriately. The service also maintained a record of compliments, made by family members and relatives.

The home employed an activities coordinator and we saw people taking part in an activity during the inspection.

On the day of the inspection, the home manager was not present. Two care co-ordinators had been tasked with overseeing the home in their absence. We observed there to be a lack of visible leadership on the day of the inspection. For example, in communal areas we saw people weren’t always seated into chairs safely and sat on appropriate pressure relieving cushions. There was nobody overseeing that these tasks were completed correctly by staff, with the co-ordinators predominantly based in the reception area and the senior carer undertaking a medication round for large parts of the day.

The manager undertook audits of areas such as care plans, medication and the environment. The provider also undertook regular audits to ensure high standards were being maintained. However, we questioned the effectiveness of these given they did not highlight the concerns we had identified such as a lack of care plan and risk assessment updates, missing life history information and no cream charts being in use.

One member of staff told us an open and transparent culture was not promoted at the home and that if staff caused a problem for the home during a CQC inspection, that they would be ‘Found out’.

The home had a range of policies and procedures in place which provided staff with guidance and advice about various systems and processes to follow.

We saw minutes from recent team meetings, where staff told us they felt able to raise concerns and contribute towards discussions.

We asked the following five questions.

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Is the service safe?

Both the people who lived in the home and their relatives were pleased with the care provided and felt their views were respected and listened to. One person said: 'I can sit here knowing I'm safe.'

The staff worked in a safe and hygienic way and used appropriate protective clothing. There were enough staff to meet the needs of the people who lived in the home and a member of the management team was available on call in case of emergencies.

Staff personnel records contained all of the information required by the Health and Social Care Act such as pre-employment checks. This meant the provider could demonstrate that staff employed to work at the home were suitable and had the skills and experience needed to support the people who lived in the home.

The registered manager and the staff we spoke with understood the importance of safeguarding vulnerable adults, could identify potential abuse and knew how to report any incidents of abuse. One relative we spoke with said: 'I feel perfectly happy with her safety.'

Is the service effective?

People told us they were happy with the care that had been delivered and their care records were up to date and signed by them where appropriate. One relative said: 'Her health has improved massively since she has been there.'

Care records confirmed people's preferences and needs had been recorded and care and support had been provided in accordance with people's wishes. One person said: 'You can enjoy your life the way you want it.'

We heard from staff information was shared effectively. Several ways of sharing information were used which included staff meetings, handovers, daily records, and monthly reviews.

Is the service caring?

People were supported by kind and attentive staff. We saw care workers showed patience and encouragement when supporting people. One relative said: 'The individual care is second to none.' One person who lived in the home said: 'The manager is a darling, full of compassion.'

Is the service responsive?

People's needs had been assessed before they were admitted to the home. Their needs for support and treatment were carefully described so care workers knew exactly what tasks to undertake. Changes in people's care needs were reported to the senior carers and they briefed care staff.

One person who lived in the home said: 'They have night staff checking on people when they are not well.' A relative we spoke with said: 'Instantly they tell me how Mum's been today.'

Is the service well-led?

Relatives praised the leadership of the home. One said: 'The manager is very good at getting things done.' Another relative said: 'The manager and I have discussions about what can be done to improve life for my mum.'

Staff had a good understanding of the culture of the home and quality assurance processes were in place. We saw the results of customer satisfaction surveys done in July 2014 and we saw evidence of feedback which had been acted upon. Responses included: 'We think the management is very professional and understand the resident's requirements.' A meeting for people who lived in the home was held regularly to seek suggestions for any improvements required.

Staff told us they were clear about their roles and responsibilities and were well supported. One said: 'They listen to us and get our thoughts.' Another staff member said: 'I can just come in and tell the manager if I think there is a better way to do things.'

People we spoke with were unaware of what medicines they were prescribed, however no-one raised any concerns about how their medicines were looked after or given to them. One person told us that they got their painkillers when they needed them and another told us that the care workers looked after her and that her tablets were given to her every day.

We looked at a sample of care plans and found that they contained nutritional assessments and a malnutrition universal screening tool (MUST). MUST assessments had been reviewed on a monthly basis and updated where necessary.

We spoke with people living at the home and their visitors. Comments included: "X is very content and I am happy with the care." "They look after X very well." "They are caring." "They let me know if X is not well."

We saw that there were enough staff to meet peoples care needs. Staff spoken with told us they had regular staff meetings and were supported by the manager.

We walked around the home and saw that all areas were clean and tidy. We looked at a sample of bedrooms and saw that people brought photographs and ornaments to make their rooms more comfortable.

We saw that paper records were stored securely and electronic records were password protected.

We could not find any evidence in the care files or daily records that instructions in regards to nutritional risks had been implemented. We spoke with the cook during the inspection and we were told that he had not received any specific instructions in regard to supplementing foods. However we were told that all food contained full fat milk and extra cream. We were told when people had any special dietary needs, such as diabetes, the kitchen staff were informed.

We had received information of concern in regards to the number of staff on duty to care for people, particularly at weekends. The inspection was undertaken on a Sunday to follow up this information of concern. We observed that people who used the service were left unsupervised for long periods in the communal areas and staff were not readily visible throughout the home. We observed people wandering around the corridors, with no staff available.

We followed up concerns about medicine management found at the last inspection. Medicines were generally stored securely. Records were not always complete and people did not always receive their medicines as prescribed.

People's care records contained enough information to show how they were to be supported and cared for. They also showed that people gave consent to their care and treatment.

We identified several issues of concern in relation to the management of medicines.

Not enough staff were provided to ensure the safety and welfare of the people using the service.

An effective complaints procedure was in place and people knew how to make a complaint.